Status epilepticus refers to continuous seizure activity lasting at least 5 minutes or two or more discrete seizures with incomplete recovery between them. It can present with obvious convulsions or subtle movements and altered consciousness. Common causes include preexisting epilepsy, infections, drugs, trauma, and strokes. Treatment involves aggressive medication like benzodiazepines, phenytoin, phenobarbital, or midazolam to stop seizures, with monitoring and management in intensive care if refractory. Outcomes are generally good if treated promptly but mortality is higher in elderly patients.

1. Status Epilepticus
DEFINITION
The term status epilepticus (SE) refers to continuous seizure activity lasting at least 5 min, or two
or more discrete seizures with incomplete recovery of consciousness between them.
ICD-10 CODES
G41
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Patients are typically unresponsive and may have obvious tonic, clonic, or tonic-clonic
movements of the extremities (convulsive status epilepticus).
• Some patients are unresponsive or have an altered level of consciousness with no clear
observable repetitive motor activity (non-convulsive status epilepticus).
• Clinical manifestations can evolve and can become subtle with only small amplitude twitching
movements of the face, limbs, or eyes.
ETIOLOGY
• Preexisting epilepsy with breakthrough seizures or low anticonvulsant drug levels
• Central nervous system infection or tumor
• Drug toxicity or metabolic disturbance
• Central nervous system hypoxia
• Head trauma
• Stroke
WORKUP
Because SE is an emergency with substantial risk of morbidity and mortality if not treated
immediately, treatment must be early and aggressive, not postponed until an etiology is
determined.

2. LABORATORY TESTS
• While treatment is being initiated: glucose, electrolytes, blood urea nitrogen, arterial blood
gases, drug levels, complete blood count, urinalysis, toxicology screens.
• Lumbar puncture in children with fever and in adults suspected to have meningitis or encephalitis
IMAGING STUDIES
Unless the etiology is known, CT or MRI of the brain is recommended as soon as possible after
seizures have been controlled.
OUTCOME
• Generally favorable if treated promptly and there is no underlying acute symptomatic cause such
as an underlying central nervous system lesion or systemic metabolic insult.
• Overall mortality rate is 22%; higher in the elderly (38%) and substantially lower in children
(2.5%). Difference in mortality rate is mainly because SE in the elderly is more often the result of an
acute symptomatic cause.
• Because of varied clinical presentations of SE, without an EEG there is no clinical basis for being
certain that seizures have stopped unless the patient regains full consciousness.
• EEG provides definitive information about seizure cessation. If available, use of
EEG in the management of SE is highly recommended.

3. Management of Status Epilepticus. Department of Internal Medicine.
Kimberley Hospital Complex. 2011.
Time, short list Action
Step 1
0–5 minutes ABC,Labs
Diagnose; give oxygen; ABC's; obtain IV access;
begin ECG monitoring; draw blood for glucose,
UEC,magnesium, calcium, phosphate, FBC, LFTs,
AED levels, ABG.
Thiamine
Dextrose
Benzodiazepines
Thiamine 100 mg IV50 ml of Dextrose 50% IV
unless adequate glucose known
Lorazepam 4 mg IV over 2 mins; if still seizing,
repeat × 1 in 5 mins. Or Diazepam10mg x 3 at a rate
of 5 mg/min.
If no rapid IV access, give Diazepam 20 mg PR or
Midazolam 10 mg intranasally, buccally or IM
Step2
5–30 minutes Phenytoin Or Valproate Twice
Begin Phenytoin 20 mg/kg IV (50 mg/min), with
blood pressure and ECG monitoring.
Additional 10mg/kg if seizures persist. Or IV
Valproate: 30mg/kg–40mg/kg over
approximately 10 minutes. If still seizing,
additional 20 mg/kg over approximately 5
minutes.
REFRACTORY SE Ideally managed in an Intensive Care Unit.
Step 3
30–60 minutes
Phenobarbital Or Midazolam
Phenobarbital
Or
Midazolam
IV Phenobarbital: 20 mg/kg IV (100 mg per min).
Additional 10mg/kg if seizures persist.
Or
Midazolam 0.2mg/kg IV Bolus to continue
0.4mg/kg/h infusion(60mg in 200ml N/S
over 2 hours)
Airway must be protected, mechanical ventilation
may be required.
Step 4
> 60 minutes
Propofol Or Thiopentone
IV Propofol 2mg/kg bolus , 2-10mg/kg/h for no
more than 36 h Or Thiopentone 100-200mg
bolus over 20 seconds then 50mg boluses every
2 to 3min until seizure suppression, then 3-
5mg/kg/h infusion.